NSW PAEDIATRIC SERVICE CAPABILITY FRAMEWORK...Tool 7: Children and adolescents in paediatric services requiring mental health care. Each Tool focuses on assessment of specific elements

NSW PAEDIATRIC SERVICE CAPABILITY FRAMEWORK

COMPANION TOOLKIT

2 Paediatric Service Capability Framework: Companion Toolkit NSW Health

NSW MINISTRY OF HEALTH 73 Miller Street NORTH SYDNEY NSW 2060 Tel. (02) 9391 9000 Fax. (02) 9391 9101 TTY. (02) 9391 9900 For information on this document please contact: Health and Social Policy Branch Email. [email protected] www.health.nsw.gov.au/kidsfamilies/ This work is copyright. It may be reproduced in whole or in part for study or training purposes subject to the inclusion of an acknowledgement of the source.

It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above requires written permission from the NSW Ministry of Health.

© NSW Ministry of Health 2017 SHPN (HSP) 160459

ISBN 978-1-76000-528-3 (print) ISBN 978-1-76000-529-0 (online) Further copies of this document can be downloaded from the NSW Ministry of Health website http://www.health.nsw.gov.au/kidsfamilies/

June 2017

mailto:[email protected]

http://www.health.nsw.gov.au/kidsfamilies/

http://www.health.nsw.gov.au/kidsfamilies/

Paediatric Service Capability Framework: Companion Toolkit NSW Health 3

Contents

Overview of the NSW Paediatric Service Capability Framework and the Companion Toolkit ............ 4

Tool 1: Establishment and operation of paediatric short stay and acute review services ................... 5

Tool 2: Close observation capability in paediatric wards ................................................................. 12

Tool 3: Emergency surgery for children: Implementation of LHD designated surgical sites and the

emergency department algorithm ........................................................................................ 17

Tool 4: Paediatric Clinical Emergency Response System (CERS) and beyond facility escalation

process ................................................................................................................................ 21

Tool 5: Involvement of paediatricians in the care of children in NSW hospitals ............................... 25

Tool 6: Child friendly and child safe health facilities ........................................................................ 29

Tool 7: Children and adolescents in paediatric services requiring mental health care ..................... 37


OVERVIEW OF THE NSW PAEDIATRIC SERVICE CAPABILITY

FRAMEWORK AND THE COMPANION TOOLKIT The aim of GL2017_010 NSW Paediatric Service Capability Framework (the Framework) is to outline a

networked approach to connect and support paediatric acute care services to improve accessibility;

equity and safe care as close to home as possible, whether in rural, regional or metropolitan locations.

The Framework provides a mechanism for Local Health Districts (LHDs) to assess the planned service

capability of their facilities. Each facility must be able to be provide all the clinical services described for

their paediatric service capability level.

LHDs should use the Paediatric Service Capability Operational Level Checklists (Appendix 2 of the

Framework) to assess their acute care paediatric health services, and identify strengths and areas for

improvement to enhance their service capabilities. The checklists outline the essential elements required

by paediatric medicine services and surgery for children services to function at each specific service

capability level.

This Companion Toolkit for the Framework was developed to address identified priorities in improving or

enhancing the capabilities of NSW Health services in the delivery of best practice contemporary care,

with particular emphasis on paediatric services in general hospitals.

The Toolkit consists of seven individual tools:

Tool 1: Establishment and operation of paediatric short stay and acute review services

Tool 2: Close observation capability in paediatric wards

Tool 3: Emergency surgery for children: Implementation of LHD designated surgical sites and the

emergency department algorithm

Tool 4: Paediatric Clinical Emergency Response System (CERS) and beyond facility escalation

process

Tool 5: Involvement of paediatricians in the care of children in NSW hospitals

Tool 6: Child friendly and child safe health facilities

Tool 7: Children and adolescents in paediatric services requiring mental health care.

Each Tool focuses on assessment of specific elements of the identified priority area, providing a deeper

analysis of activities to support completion of the overall assessment outlined in the Framework.

http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2017_010.pdf


TOOL 1: ESTABLISHMENT AND OPERATION OF PAEDIATRIC

SHORT STAY AND ACUTE REVIEW SERVICES This tool focuses on the optimal journey for children who have presented to a NSW public hospital and

outlines the requirements for a paediatric short stay service and acute review service. It applies to any

NSW public health facility that provides care to paediatric patients1. It is proposed that this tool be used

by services to:

Undertake self-assessment to identify strengths and opportunities to develop or enhance

paediatric short stay and acute review services.

A paediatric short stay service provides same day admission capability for children. Patients are

mostly, but not always, unplanned. The service admits patients directly from the Emergency Department

(ED) requiring continuing observation or care for a number of hours, including children whose disposition

is dependent on response to treatment, or who are likely to be discharged (e.g. children with a head

injury or asthma).

Planned presentations may also be suitable for admission to short stay services. These include, but are

not limited to, children who require: intravenous access and infusions, central venous support, procedural

care (e.g. nasogastric tube reinsertion, food challenges and at- risk immunisations).

A paediatric acute review service is one in which children:

Return to the hospital for planned acute review (usually non-admitted) and possibly treatment

subsequent to (usually the day after) their departure from the ED and/or the hospital

Present on a planned basis for a procedure that might otherwise have required admission or a

longer stay in hospital e.g. wound dressing changes, regular scheduled chemotherapy,

intravenous (IV) antibiotic administration2.

Paediatric short stay and acute review services3 provide:

Appropriate, high quality care with escalation of care when necessary

Timely departure from the ED

A reduction in unnecessary admissions and/or reduction in length of stay

Alternative models of care to overnight inpatient admission.

1 ‘Paediatric’ includes any patient under the age of 16 years

2 Such patients may also be managed as short stay admissions depending on the child’s clinical status

3 ‘Acute service’, for the purpose of this document, does not refer to urgent care centres

The use of the term ‘paediatrician’ is used throughout the document however it is acknowledged that in some facilities there may be other specialists providing medical support to paediatric short stay and acute review services such as General Practitioner (GP) or Visiting Medical Officer (VMO) There are many names given to paediatric short stay/acute review services including ‘Paediatric Short Stay Unit’, ‘Paediatric Acute Review Clinic’, ‘Paediatric Ambulatory Care Unit’, ‘Paediatric Ambulatory Unit’ and ‘Paediatric Assessment Unit’

What are Paediatric Short Stay and Acute Review Services?


Children requiring short stay admission should be accommodated in paediatric specific areas/safe beds.

Where this is not possible, the requirements set out in PD2014_040 Emergency Department Short Stay

Units must be followed.

Paediatric short stay services Focus on children in the ED who are clinically stable

and require a short period of further assessment or treatment

Reduce the length of stay for unplanned presentations that would require an overnight admission if the short stay service was not available

Facilitate opportunities for planned short stay admissions as part of continuing care or day surgery

Typically operate during extended daytime hours

Form part of the paediatric inpatient area, the ED or operate as a standalone service

Paediatric acute review services Provide options for planned, non-admitted patient

review (+/- treatment) after discharge from an ED or hospital

Facilitate planned care for procedures such as wound dressings, regular scheduled

chemotherapy, and IV antibiotic administration

Operate during the day, preferably morning, and may be combined with short stay or comparable

services

Establishing/Operating Paediatric Short Stay and Paediatric Acute Review Services

4. Intake/admission referrals and criteria

5. Staffing and resources 6. Escalation of care

1. Design 2. Governance arrangements

3. Hours of operation and appointments

http://www0.health.nsw.gov.au/policies/pd/2014/pdf/PD2014_040.pdf

http://www0.health.nsw.gov.au/policies/pd/2014/pdf/PD2014_040.pdf


Checklist for establishing/operating paediatric short stay or acute review services

Site:

Review conducted by:

Date of review:

Design* (see additional numbered notes at the end of this tool)

1. Is/are dedicated space(s) available?

Yes

☐ Comments

No

☐

Date to be completed by

2. Has a risk assessment been undertaken including the local resources available to support the service such as access to allied health and pharmacy?

Yes

☐ Comments

No

☐


3. Configuration/s

3a. Paediatric short stay service for unplanned admissions within or adjacent to an ED.

Yes

☐ Comments

No

☐


3b. Paediatric short stay service for planned admissions within or adjacent to a paediatric inpatient ward.

Yes

☐ Comments

No

☐


3c. Paediatric acute review service within a paediatric inpatient ward, outpatient department or dedicated space in an ED.

Yes

☐ Comments

No

☐


3d. Stand-alone paediatric short stay and/or acute review service in a facility with no paediatric inpatient ward.

Yes

☐ Comments

No

☐



4. Does design of the service adhere to requirements for child-friendly and child-safe facilities?4

Yes

☐ Comments

No

☐


Governance arrangements

5. Have collaborative arrangements between the ED and paediatric service been established?

Yes

☐ Comments

No

☐


5a. Are there clearly defined roles, including responsibilities for provision of support and supervision of paediatric trainees/junior medical staff when working in ED?

Yes

☐ Comments

No

☐


6. Model/s* (see numbered notes at the end of this tool)

6a. Paediatric short stay and/or acute review service that is co-located with the ED and is managed by the emergency service, with paediatric expertise provided on request.

Yes

☐ Comments

No

☐


6b. Paediatric short stay and/or acute review service located within a paediatric in-patient ward is managed by the paediatric service with continuing input from the emergency service.

Yes

☐ Comments

No

☐


Hours of operation and appointments

7a. Have the hours of operation needed to provide an effective service to the local paediatric population been

established? * (see numbered notes at the end of this tool)

Yes

☐ Comments

No

☐


4 See GL2017_010 NSW Paediatric Service Capability Framework

http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2017_010.pdf


7b. Combined short stay and acute review service operating 8am to 10pm, 7 days per week, with staggered shifts?

Yes

☐ Comments

No

☐


7c. Paediatric short stay service co-located with ED for unplanned admissions extending to overnight stays?

Yes

☐ Comments

No

☐


8. Have the processes required to arrange appointments for medical review been established?

Yes

☐ Comments

No

☐


Intake/admission referrals and criteria

9. Have agreed local criteria for risk assessment and admission of children been established, recognising that flexibility is required?

Yes

☐ Comments

No

☐


10. Is a process in place to assess each child for suitability for the proposed service to ensure safe and quality care?

Yes

☐ Comments

No

☐


11. Is a process in place for a more stringent assessment of children deemed suitable to be cared for out of hospital, prior to leaving the hospital, with consideration given to haemodynamic stability, parent/carer access to a phone and transport for a return visit/review?

Yes

☐ Comments

No

☐



12.

Have contraindications for admission to paediatric short stay and acute review services been established? These may include patients:

With comorbidities that are likely to affect the predictability of the disease progression

Who are clinically unstable

With an uncertain or unclear provisional diagnosis Who are subject to any suspicion of child protection issues.

Yes

☐ Comments

No

☐


Staffing and resources

13. Are there adequate staff, equipment and other resources for the paediatric short stay and acute review services (for either planned or unplanned patients)?

Yes

☐ Comments

No

☐


14. Has the appropriate level of staffing for the service been established? This includes, but is not limited to, points 14a to 14e below.

Yes

☐ Comments

No

☐


14a. Are paediatricians available for review and supervision of care/treatment?

Yes

☐ Comments

No

☐


14b. Is there defined nursing leadership for the service/s?

Yes

☐ Comments

No

☐


14c. Has a roster that covers each shift incorporating holiday cover been established?

Yes

☐ Comments

No

☐



14d. Is age-specific and appropriately maintained paediatric equipment available?

Yes

☐ Comments

No

☐


14e. Is there availability of training and education and opportunities for extension of skills, such as participation in procedures?

Yes

☐ Comments

No

☐


Escalation of care

15. Have procedures been established for escalation of the care of any child who is assessed as requiring a higher level of care?

Yes

☐ Comments

No

☐


* Additional notes by question

1 The ideal location for a paediatric short stay and/or acute review service is to adjoin both the ED and the paediatric inpatient ward. This allows for use of such services by both ED and the ward. It is acknowledged that variations will exist according to local circumstances and physical environment. It is also acknowledged that aspects of paediatric short stay or acute review services may be separated across different locations, according to optimal arrangements for the respective patient cohorts. The most appropriate configuration should be chosen according to local circumstances.

6 The essential principle is that both the emergency and paediatric services are engaged in the process. Shared care arrangements may be considered with the paediatric service providing additional clinical support to children in EDs.

7a Variations may occur according to local circumstances

7b This allows for the contrasting demands of planned acute reviews earlier in the day and unplanned ED flows in the late afternoon and evening.

8 An ideal model for an acute review service is one in which appointments for planned medical review occurs in the morning to allow for medical oversight of unplanned patients from ED in the afternoon.

10 The main source of referrals is the ED. Other referral sources (for planned return visits) include paediatric wards (post-discharge) outpatient clinics and GPs. Surgical services may refer patients for pre- or post-operative care.

15 Escalation of care requires consultation with the rostered or allocated paediatrician. If transfer is needed, destinations may include a paediatric inpatient ward or a facility with a higher level paediatric service in line with local Clinical Emergency Response System (CERS) policy.


TOOL 2: CLOSE OBSERVATION CAPABILITY IN PAEDIATRIC

WARDS

In recent years there has been a trend of increased acuity of patients in paediatric wards in general

hospitals. This trend is a consequence of a combination of factors: increases in the paediatric population;

increased numbers of higher acuity paediatric presentations to emergency departments (ED), as

measured by the Australasian Triage Scale; the advent of new therapies which are more widely available

and practised outside the specialist children’s hospitals (e.g. high-flow nasal oxygen therapy) and higher

thresholds for transfer to a specialist children’s hospital. Accordingly, these higher acuity paediatric

patients who require close observation may be appropriately managed closer to home, with an

appropriate level of capability in place.

This tool outlines the requirements for providing close observation to eligible patients in a paediatric

ward. It is intended for any NSW public health facility that provides care to paediatric patients5 in a

dedicated paediatric ward. It is proposed that this tool be used by services to:

Undertake self-assessment to identify strengths and opportunities to introduce or enhance close

observation capability in line with the requirements outlined in this tool.

Close observation involves a higher level of monitoring, observation and care for individual patients who

are vulnerable to critical illness. This is more intensive compared to standard ward-based care. Close

observation of a paediatric patient is determined on the basis of clinical need.

Patients with a range of medical and surgical conditions may require close observation for a period of

time but not all patients with the same condition will require close observation. Paediatric patients

requiring a higher level of medical and nursing care should generally receive this in a dedicated

paediatric in-patient ward.

Escalation beyond close observation status – awaiting retrieval

Thresholds for escalation beyond close observation status should be developed and documented to

assist staff in their decision making. If staff are unavailable to meet the needs of a close observation

patient then transfer of the patient to a higher acuity facility is required.

There may be a need for temporary local escalation of care beyond close observation when:

the agreed upper threshold of safe care in close observation beds on a paediatric ward is exceeded, and

patients are awaiting transfer to a specialist children’s hospital.

These patients and their conditions are such that they may be too sick for the paediatric service to

manage. This scenario is usually of short duration and needs to be managed in close collaboration

between the paediatric service and colleagues in the emergency department, anaesthesia and/or general

intensive care unit.

5 ‘Paediatric’ includes any patient under the age of 16 years.

What is Close Observation?


Checklist for establishing/operating close observation capability in a paediatric ward

Site: Review conducted by:

Date of review:

Process for activation of close observation beds

1.

Is there a process in place for consultative decision-making to activate a close observation bed including discussion between:

Paediatrician designated as Clinical Lead of the Paediatric Service or delegate

Ward Nursing Unit Manager or Team Leader

Patient Flow Manager or delegate.

Yes

☐ Comments

No

☐


2. Has the maximum number of paediatric close observation beds that can be activated at any one time to assist with individual paediatric patient needs been defined?

Yes

☐ Comments

No

☐


3.

Have documented processes been established and made easily accessible to staff for:

Activation of close observation beds (including approval processes)

Escalation and transfer to a specialist children’s hospital

De-escalation of care?

Yes

☐ Comments

No

☐


Medical review and care planning

4. Have procedures been established that ensure paediatric vital signs for close observation patients are recorded at least hourly on the correct for age Standard Paediatric Observation Chart (SPOC)?

Yes

☐ Comments

No

☐


5. Have procedures been established that ensure medical reviews of each patient requiring close observation occur at least 8 hourly?

Yes

☐ Comments

No

☐



6.

Have procedures been established that ensure additional reviews can be initiated by nursing staff at any time if there are any concerns, including from parents, or any deterioration in clinical condition that is in the Yellow Zone

as per the SPOC? * (see additional numbered notes at the end of this tool)

Yes

☐ Comments

No

☐


7. Have procedures been established that ensure all reviews are documented in the medical record?

Yes

☐ Comments

No

☐


8. Have procedures been established that ensure a documented treatment plan, including altered calling criteria on the SPOC, is in place for all patients?

Yes

☐ Comments

No

☐


9. Is the threshold for escalation of care and transfer to a children’s hospital documented, consistent with local paediatric service policy?

Yes

☐ Comments

No

☐


10. Have procedures been established that ensure, where paediatric close observation patients are admitted under a non-paediatric team, consultation occurs with the local paediatrician on call?

Yes

☐ Comments

No

☐



Additional staffing processes and resources for close observation

11. Have processes been established to ensure that there is a paediatrician available 24 hours a day/7 days a week to supervise patient care as well as an onsite junior medical officer with appropriate skills available 24 hours a day/ 7 days a week?

Yes

☐ Comments

No

☐


12. Have processes been established to ensure that safety of patients in the paediatric ward is maintained by staffing of close observation beds with appropriately skilled nursing staff, without compromise to care of other patients?

Yes

☐ Comments

No

☐


13. Have processes been established to ensure that the paediatric ward roster is flexibly managed to ensure appropriate staffing across shifts?

Yes

☐ Comments

No

☐


14. Have processes been established to ensure that nursing skill mix and numbers are appropriate to provide care for patients requiring close observation?

Yes

☐ Comments

No

☐


15. Have processes been established to ensure that skilled nursing and medical staff have access to relevant

education and training? * (see additional numbered notes at the end of this tool)

Yes

☐ Comments

No

☐


16. Have processes been established to ensure that staff on paediatric wards who care for patients requiring close observation have completed all aspects of mandatory training as relevant to the care of a sick child?

Yes

☐ Comments

No

☐



17. Is there an inventory of equipment required for invasive and non-invasive respiratory support?

Yes

☐ Comments

No

☐


18. Is relevant equipment accessible at all times?

Yes

☐ Comments

No

☐


De-escalation of care

19. Have processes been established to ensure that, as a child’s condition improves, the decision that a patient no longer requires close observation is made collaboratively between the nursing Team Leader/In Charge of Shift and senior medical staff?

Yes

☐ Comments

No

☐


20. Have processes been established to ensure that, as a child’s condition improves, the decision that a patient no longer requires close observation is documented in the patient’s medical record and notified to the Patient Flow Manager or delegate?

Yes

☐ Comments

No

☐


21. Have processes been established to ensure that, as a child’s condition improves, the decision to de-escalate from close observation is made independently of demand for close observation or paediatric beds?

Yes

☐ Comments

No

☐


* Additional notes by question

6 Red Zone deterioration initiates Rapid Response

15 Training includes recognition and management of a deteriorating child and paediatric resuscitation, as well as education linked to specific conditions covered in the NSW paediatric clinical practice guidelines

19 There is no minimum or maximum time a child can be classified as needing close observation. It is entirely a clinical decision e.g. some children may need close observation for a few hours during an infusion, but some with complex needs may need close observation for the majority of their admission


TOOL 3: EMERGENCY SURGERY FOR CHILDREN:

IMPLEMENTATION OF LHD DESIGNATED SURGICAL SITES

AND THE EMERGENCY DEPARTMENT ALGORITHM

This tool focuses on enhancing and standardising the process for children presenting to emergency

departments (ED) with a potential surgical problem. It provides a checklist for assessing implementation

of LHD designated surgical sites and the ED algorithm which was published in June 2014 as part of the

Surgery for Children in Metropolitan Sydney: Strategic Framework. It applies to any NSW public health

facility that provides care to paediatric patients6. It is proposed that this tool be used by services to:

Undertake self-assessment to identify strengths and opportunities for improvement in implementing LHD designated sites and the ED algorithm template.

An important part of surgical care for children is effective pain assessment and management. Processes

should be in place to ensure that children’s pain is appropriately managed from their time of presentation

to ED and throughout their hospital stay.

There should be:

One or more designated paediatric surgical sites in each LHD that provide assessment and

treatment for children with potential surgical problems.

Agreement about the complexity, age limits and type of surgery that can be provided safely and

reliably

Timely access to surgical teams

Processes for consultation with, referral to, and retrieval from, a higher level of paediatric surgical

care

Processes for referral from other sites

Appropriate anaesthetic capability and cover

Engagement with and support from the paediatric medical service

Processes for regular review and escalation of care.


What is needed to support safe and reliable assessment and

treatment as close to home as possible for children with

potential surgical emergency?

http://www.kidsfamilies.health.nsw.gov.au/media/205699/2-page-ED-Algorithm-FINAL.PDF

http://www.kidsfamilies.health.nsw.gov.au/publications/paediatrics-surgery-for-children-in-metropolitan-sydney-strategic-framework/


Checklist for implementation of Local Health District Designated Surgical Sites and the Emergency Department Algorithm


Date of review:

LHD Designated Surgical Sites

1. Has the LHD designated one or more Paediatric Surgical Sites, or is there a formal agreement with a similar service capability level of paediatric surgical site in an adjacent jurisdiction?

Yes

☐ Comments

No

☐


2. Does the LHD designated Paediatric Surgical Site/s meet the criteria for level 4/5 service capability in Paediatric

Medicine? * (see additional numbered notes at the end of this tool)

Yes

☐ Comments

No

☐


ED Algorithm

3. Has the Surgery for Children in Metropolitan Sydney ED Algorithm Template been adopted and/or adapted for local use?

Yes

☐ Comments

No

☐


Local Surgical Team Requirements #

4. Is there a documented process for timely surgical team participation?

Yes

☐ Comments

No

☐


5. Is there a nominated general surgery trainee on call 24 hours to see children with surgical problems?

Yes

☐ Comments

No

☐


6. Have locally agreed lower age thresholds been set?

Yes ☐ Orthopaedic/ENT/Plastics/Ophthalmology

Age:

No ☐ General/Urology/Other

Intra-abdominal (e.g. appendicectomy) Age:


Other site Age:


Other Local Requirements

7. Is the paediatric medical service at the same or higher level of service capability? * (see additional numbered notes at the

end of this tool)

Yes

☐ Comments

No

☐


8. Is there a documented process for paediatric team participation?

Yes

☐ Comments

No

☐


9. Is there a nominated doctor with skills in the assessment of management of children with acute medical problems, on call 24 hours to see children with surgical problems?

Yes

☐ Comments

No

☐


10. Is there timely and appropriate anaesthetic capability and cover?

Yes

☐ Comments

No

☐


11. Is there adequate postoperative care capability and cover? * (see additional numbered notes at the end of this tool)

Yes

☐ Comments

No

☐


Patient Flow and Escalation Processes #

12. Is there a documented process for referral/transfer in from other sites?

Yes

☐ Comments

No

☐


13. Is there a documented process for referral or retrieval to a specialist children’s hospital?

Yes

☐ Comments

No

☐



14. Is there a documented process for regular review and triggers for escalation of care?

Yes

☐ Comments

No

☐


15. Is there a documented process for management and escalation of rare situations e.g. intraoperative complication that prevents extubation?

Yes

☐ Comments

No

☐


SCROTAL or TESTICULAR PAIN #

16. Is there a documented process for seeking urgent senior surgical review and a policy to explore the scrotum locally unless clinically contraindicated?

Yes

☐ Comments

No

☐


# Please append additional information as required.

* Additional Notes by question

2 Criteria for level 4/5 role delineation in Paediatric Medicine includes an appropriately staffed paediatric ward as well as

essential elements of child friendly and child safe facilities see NSW Paediatric Service Capability Framework for detail

7 Documented processes must be in place regarding situations where the designated Clinical Lead of Paediatric Service or

delegate must be contacted

10 Adequate post-operative cover refers to the presence of appropriately skilled staff to care for the patient


TOOL 4: PAEDIATRIC CLINICAL EMERGENCY RESPONSE

SYSTEM (CERS) AND BEYOND FACILITY ESCALATION

PROCESS

This tool focuses on the implementation of the paediatric aspects of the paediatric Clinical Emergency

Response System (CERS) and beyond facility escalation process contained within NSW Health policy

directive PD 2013_049 Recognition and Management of Patients who are Clinically Deteriorating. It

applies to any NSW public health facility that provides care to paediatric patients7. It is proposed that this

tool be used by services to:

Undertake self-assessment to identify strengths and opportunities for improvement in

implementing their paediatric escalation documentation and practice with the emphasis on the

importance of a consistent stepped approach to the escalation of care.

All health facilities in NSW must have clinical emergency response systems (CERS) consistent with NSW

Policy Directive PD 2013_049 Recognition and Management of Patients who are Clinically Deteriorating.

The PD describes a defined three step process for paediatric responses and escalation of care, including

timely access to care following paediatric clinical deterioration in a rural setting.

The actions arising from the three stepped process are:

Step 1: Contact the most senior clinical expertise available in the facility of presentation

Step 2: Contact the designated 24/7 role delineated level 4/5 paediatric service (LHD)

Step 3: Contact NETS for consultation and/or transfer of care (state-wide).

Steps 2 and 3 are ideally undertaken as part of a three-way teleconference between the presenting

facility, the formally networked role delineated level 4/5 paediatric service, and NETS to determine the

appropriate care and destination of the child. When a child presents to a role delineated level 4/5 (rural or

metropolitan) paediatric service, Step 2 is not required.

Clinical urgency overrides designated steps within the paediatric CERS and beyond facility escalation

document.

This self-assessment tool supports LHDs in evaluating their paediatric escalation documentation and the

three-stepped approach to escalation of paediatric care. Despite a rural emphasis, the key elements of

the tool apply to all LHDs.


What are the requirements for paediatric clinical emergency

response systems?

http://www0.health.nsw.gov.au/policies/pd/2013/PD2013_049.html

http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2013_049.pdf


Checklist for documentation of Paediatric Clinical Emergency Response System (CERS) and beyond facility escalation process


Date of review:

Clinical Emergency Response System Documentation

1. Does the document deviate from the information outlined in PD2013_049 Recognition and Management of Patients who are Clinically Deteriorating?

Yes

☐ Comments

No

☐


2. Has the document been developed in the format of an algorithm/one page flow-chart? * (see additional numbered notes at the

end of this tool)

Yes

☐ Comments

No

☐


3. Is the document/algorithm accessible in all areas within all facilities where children may be seen?

Yes

☐ Comments

No

☐


4. Does the document clearly link to the SPOC coloured zones and additional calling criteria? * (see additional numbered notes at

the end of this tool)

Yes

☐ Comments

No

☐


5. Does the document include a list of actions consistent with the three SPOC coloured zones?

Yes

☐ Comments

No

☐


6. Is the document consistent with response timeframes outlined in PD2013_049 Recognition and Management of Patients

who are Clinically Deteriorating? * (see additional numbered notes at the end of this tool)

Yes

☐ Comments

No

☐







Paediatric specific 3-stepped approach to escalation of care

7. Does the document contain information that promotes a 3-stepped approach to escalation within & beyond the facility? * (see additional numbered notes at the end of this tool)

Yes

☐ Comments

No

☐


7.1

STEP 1

Clear instructions for contacting the most senior paediatric medical expertise available in the local hospital of presentation?

Yes

☐ Comments

No

☐


7.2.1

STEP 2

Clear instructions and contact details for the designated 24/7 role delineation level 4/5 paediatric service as per NSW

Heath Guide to the Role Delineation of Services? * (see additional numbered notes at the end of this tool)

Yes

☐ Comments

No

☐


7.2.2 Contact details for additional and/or alternative LHD-based services/specialties that could be included in the

review/escalation process of the patient? * (see additional numbered notes at the end of this tool)

Yes

☐ Comments

No

☐


7.3

STEP 3

Clear instructions for the consistent, state-wide escalation through NETS for consultation and/or request for transfer/retrieval?

Yes

☐ Comments

No

☐


8. Does the document clearly state that urgency supersedes the hierarchy of escalation responses?

Yes

☐ Comments

No

☐

Date to be completed

by

http://www.health.nsw.gov.au/services/Publications/role-delineation-of-clinical-services.PDF

http://www.health.nsw.gov.au/services/Publications/role-delineation-of-clinical-services.PDF


* Additional Notes:

2 LHDs may choose to have accompanying documentation such as a policy directive, guidance, procedures with this document

4 Blue Zone: “Increased Vigilance,” Yellow Zone: “Clinical Review,” Red Zone: “Rapid Response”

6 This information can be found in 'Section 4. Clinical Emergency Response System' on page 10 of Policy Directive 2013_049

7 As per PD2013_049 Recognition and management of patients who are clinically deteriorating

7.2.1 This service should be a point of advice, referral and paediatric expertise and have a 24 hour/7 days a week on call paediatric (medical) consultation as a consistent and essential component of the escalation process

7.2.2 This information reflects LHD/SHN and facility specific additional or back-up arrangement to support/supplement above mechanisms


TOOL 5: INVOLVEMENT OF PAEDIATRICIANS IN THE CARE OF

CHILDREN IN NSW HOSPITALS

This tool focuses on a standardised approach to the provision of paediatrician review and oversight in the

care of children according to standardised criteria for both time-related and clinical factors. It applies to

any NSW public health facility that provides care to paediatric patients8. It is proposed that this tool be

used by services to:

Undertake self-assessment to identify strengths and opportunities to introduce or enhance

processes, including governance structures, for involving a paediatrician in the care of a child.

Most children are admitted under the care of a paediatrician. However, children may be admitted under

the care of non-paediatric clinicians and/or in facilities without specialist paediatric services. When this is

the case, consistent processes are required to ensure paediatrician consultation, advice and oversight is

available for the management of the child.

There are many effective and collaborative arrangements in place across LHDs to ensure the

involvement of paediatricians in the care of children under the care of other medical clinicians. Such input

and oversight is intended to be respectful of the role of the clinician primarily responsible for care and is

not intended to take over that care.

All children who are in a NSW Health facility for longer than 24 hours (and earlier for children identified at

risk) should receive paediatrician review and involvement. Referral may be sought by medical clinicians,

non-medical staff members or a child’s parent/carer. As identified in the NSW Paediatric Service

Capability Framework, all LHDs are required to have a Clinical (Medical) Lead of Paediatric Services

based at their service capability level 4 or level 5 facilities.

Role and Responsibilities of designated clinical (medical) lead of paediatric service (or rostered

delegate)

Provides a paediatric approach to care for all patients regardless of the reason for admission or

admitting service

Acts as a first point of contact for early consultation and joint decision making around the care of

unwell infants, children and young people9

Acts as a single point of contact for a remote, rural and regional medical officer with a critically

unwell or deteriorating child requiring immediate paediatric consultation

Provides guidance for medical and nursing staff for when remote, rural and regional facilities

should consult with paediatricians

Acts as a single point of contact for parents/carers, health professionals and non-medical

clinicians to escalate persistent concerns about the care of a child requiring paediatric

consultation.


9 Refer to requirements in the NSW Paediatric Service Capability Framework regarding formal networked relationships

What are the requirements for involvement by a paediatrician

in a child’s care?


In addition to the time threshold identified above, a paediatrician should be involved very early in the care

of a child who10

:

Is clinically unstable

Has no definitive diagnosis

Is subject to any degree of concern for a safe patient outcome

Has no clear signs of clinical improvement following initial treatment

Is subject to any suspicion of child protection issues

Has significant co-morbidity

Shows signs or symptoms of deterioration, including but not restricted to, any Standard Paediatric

Observation Chart (SPOC) calling criteria

Warrants acute transfer to a higher role delineation level paediatric service or another hospital

because of their clinical status

Is subject to concerns expressed (including by parent/carer) regarding deterioration or change in

status, with or without documented signs.

10

As per PD2010_032 Children and Adolescents - Admission to Services Designated Level 1-3 Paediatric Medicine & Surgery

Summary of clinical triggers to initiate involvement of a paediatrician




Checklist for involving paediatricians in the care of children


Date of review:

Governance structure for a service capability level 4/5 paediatric service

1. Has a clinical (medical) lead of paediatric service been designated to have oversight for the respective population?

Yes

☐ Comments

No

☐


2. Has the geographic catchment of supported service capability levels 2 and 3 paediatric services been defined?

Yes

☐ Comments

No

☐


3. Have processes been established to ensure paediatricians on the roster (as delegates for the clinical lead of service) have responsibility and authority to become involved in the care of children presenting and/or admitted to the level 4/5 service and the facilities in the defined geographic catchment?

Yes

☐ Comments

No

☐


Telehealth

4. Is telehealth available to enhance the quality and accuracy of remote consultations?

Yes

☐ Comments

No

☐



Parent/carer request for referral

5. Have processes been established for a parent/carer to request referral to a paediatrician via the nurse in charge of the shift?

Yes

☐ Comments

No

☐


6. Have processes been established for the nurse in charge of the shift to recommend referral to the admitting medical/surgical team on the basis of a parent/carer request?

Yes

☐ Comments

No

☐


7. Have processes been established to ensure that if a recommendation is not accepted or cannot be conveyed to the admitting medical/surgical team, the nurse in charge of the shift may contact an appropriate specialist?

Yes

☐ Comments

No

☐



TOOL 6: CHILD FRIENDLY AND CHILD SAFE HEALTH

FACILITIES

This tool outlines the requirements for providing child friendly and child safe health facilities. It is

proposed that this tool be used by services to:

Undertake self-assessment to identify strengths and opportunities to introduce or enhance child

friendly and child safe health service capability.

CHILD FRIENDLY AND CHILD SAFE HEALTH FACILITIES

Child friendly service development and physical design principles deliver an appropriate environment in

which to care for paediatric patients. The requirements for child friendly and child safe health facili ties

apply across all areas where paediatric care is delivered, including but not limited to EDs, ambulatory

care, short-stay units, operating suite and inpatient units. These requirements are included in

PD2010_032 Children and Adolescents – Admission to Services Designated Level 1-3 Paediatric

Medicine and Surgery (please note that this document refers to the 2002 Role Delineation Guide).

What are the requirements of a child friendly and child safe

health facility for children?


Checklist for child friendly and child safe health facilities


Date of review:

Within new and existing services, children and their parents/carers should have access to a dedicated space that supports their needs and includes, but is not limited to:

EMERGENCY DEPARTMENT

1. Is there a separate waiting area for paediatric patients that is protected from the sights and sounds of the general waiting area, while remaining easily observable by staff?

Yes

☐ Comments

No

☐


2. Is there an appropriately equipped area suitable for the resuscitation of children?

Yes

☐ Comments

No

☐


3. Is there age appropriate equipment including wheelchair access?

Yes

☐ Comments

No

☐


4. Are there consulting and examination areas which enable privacy and confidentiality?

Yes

☐ Comments

No

☐


5. Are there appropriate facilities to care for children with behavioural and mental health presentations?

Yes

☐ Comments

No

☐



6. Is there an appropriate area for management of infectious patients and/or isolation of other patients as needed?

Yes

☐ Comments

No

☐


7. Are there consulting and treatment areas that permit and encourage parents/carers to stay with their child?

Yes

☐ Comments

No

☐


8. Are there facilities for breastfeeding mothers which provide the option of privacy?

Yes

☐ Comments

No

☐


OUTPATIENTS

9. Is there a separate waiting area for paediatric patients that is protected from the sights and sounds of the general waiting area, while remaining easily observable by staff?

Yes

☐ Comments

No

☐



Yes

☐ Comments

No

☐


11. Are there consulting and examination areas which enable privacy and confidentiality?

Yes

☐ Comments

No

☐




Yes

☐ Comments

No

☐


13. Are there consulting and treatment areas that permit and encourage parents/carers to stay with their child?

Yes

☐ Comments

No

☐



Yes

☐ Comments

No

☐


INPATIENTS

All children must be in a paediatric safe bed in any part of the hospital.

Role delineated Level 3 paediatric medical services must have a paediatric safe area or ward.

Role delineated Level 4 paediatric medical services and above must have a paediatric safe ward.

PAEDIATRIC SAFE BED

Are there beds for children that:

15. Are easily observed by nursing staff?

Yes

☐ Comments

No

☐


16. Have immediate access to paediatric specific emergency equipment?

Yes

☐ Comments

No

☐



17. Have a separate area away from the child’s bed for conducting painful procedures?

Yes

☐ Comments

No

☐


18. Have consulting and examination areas which enable privacy and confidentiality?

Yes

☐ Comments

No

☐


19. Have access to equipment for age-appropriate play?

Yes

☐ Comments

No

☐


20. Are physically separate from adult patients and protected from the sights and sounds of adult patients?

Yes

☐ Comments

No

☐


21. Are safe from potential risk from other patients, staff and visitors?

Yes

☐ Comments

No

☐


22. Are physically safe, with any dangerous equipment, medications or fluids out of reach and/or stored in locked cupboards?

Yes

☐ Comments

No

☐



23. Have a toilet and bathroom not shared with adult patients?

Yes

☐ Comments

No

☐


24. Have suitable furniture that meets Australian Standards, including cots for children less than 2 years of age?

Yes

☐ Comments

No

☐


25. Have access that does not pass through an adult ward or area, or require adult patients to pass through the paediatric area?

Yes

☐ Comments

No

☐


26. Have access to facilities that permit and encourage parents/carers to stay with their child and meet their own needs for nutrition, rest and hygiene?

Yes

☐ Comments

No

☐



Yes

☐ Comments

No

☐


PAEDIATRIC SAFE AREA/WARD These requirements are in addition to all the requirements for paediatric safe beds:

28. Is there a dedicated paediatric ward that does not admit adult patients? * (see additional numbered notes at the end of this

tool)

Yes

☐ Comments

No

☐



29. Is the area functionally separate from any adult patients, preferably with a secured door that cannot be opened by young children?

Yes

☐ Comments

No

☐



Yes

☐ Comments

No

☐


31. Is there age appropriate play equipment to meet the child’s developmental needs and for distraction purposes during procedures?

Yes

☐ Comments

No

☐


32. Are there appropriate facilities to care for children with behavioural and mental health presentations?

Yes

☐ Comments

No

☐



Yes

☐ Comments

No

☐


34. Is it decorated in a way that is comfortable and reassuring for both children and their families, with appropriate infection control procedures?

Yes

☐ Comments

No

☐



35. Are the physical safety requirements for regulated hot water temperature and secure electrical outlets met?

Yes

☐ Comments

No

☐


* Additional Notes:

28 Older adolescents who are continuing are under paediatric teams or transitioning may be admitted in a paediatric ward, preferably in a separate adolescent area.


TOOL 7: CHILDREN AND ADOLESCENTS IN PAEDIATRIC

SERVICES REQUIRING MENTAL HEALTH CARE This tool outlines the requirements for paediatric inpatient services in supporting and providing assessment and treatment for children under 16 years of age with mental health problems. The primary reason for admission may be for treatment of mental health problems, or children with other primary reasons for admission may have comorbid mental health problems requiring intervention.

The principles for determining the most appropriate treatment facility for children and adolescents who require inpatient treatment for mental health problems are detailed in the policy directive PD2011_016 Children and Adolescents with Mental Health Problems Requiring Inpatient Care.

It is proposed that this tool be used by services to:

Undertake self-assessment to identify strengths and opportunities to introduce or enhance mental health care capability in line with the principles outlined below.

There needs to be:

Agreements and joint protocols regarding access to specialist Child and Adolescent Mental

Health Service (CAMHS) advice

Established roles and responsibilities of paediatricians, local psychiatrists and CAMHS

psychiatrists

Processes regarding risk assessment, consultation, admission and referral

Care that is planned collaboratively with acute and community services

Care that is culturally appropriate

Processes to ensure continuity of care.

What are the requirements of a paediatric service in

supporting and providing assessment and treatment for

children under 16 years of age with mental health problems?




Checklist for children and adolescents in paediatric services requiring mental health care

1. Service Agreements

1a Are there clear agreements and joint protocols with local mental health services, the emergency department, paediatric services and where applicable, with the Psychiatric Emergency Care Centre (PECC) regarding access to specialist CAMHS advice?

Yes

☐ Comments

No

☐


1b Is there a procedure to establish the roles and responsibilities of paediatricians, local psychiatrists and CAMHS psychiatrists in the assessment of children and adolescents with acute mental health problems?

Yes

☐ Comments

No

☐


2. Admission processes

Are there protocols and processes to ensure:

2a A risk assessment has been performed identifying the challenges and risks of the unit and its suitability for patient groups?

Yes

☐ Comments

No

☐


2b Staffing is matched to the clinical needs of the young person and unit?

Yes

☐ Comments

No

☐


2c Consultation with the local Child and Adolescent Mental Health Service?

Yes

☐ Comments

No

☐



2d Admission under a local child and adolescent psychiatrist where available?

Yes

☐ Comments

No

☐


2e Admission under a paediatrician with consultation-liaison support?

Yes

☐ Comments

No

☐


2f Referral and escalation of a patient to a higher level paediatric setting or statewide Child and Adolescent Mental Health inpatient unit when necessary?

Yes

☐ Comments

No

☐


3. Collaborative Care Planning

3a Are there protocols for collaborative care planning with mental health service providers (including GPs, private providers, schools and CAMHS) children, young people and families?

Yes

☐ Comments

No

☐


4. Culturally Appropriate Care

4a Are there protocols that ensure care is culturally accessible and appropriate?

Yes

☐ Comments

No

☐


4b Are there protocols to ensure that appropriate referral is made?

Yes

☐ Comments

No

☐



5. Continuity of Care

5a Are there processes to ensure that appropriate community based professionals are engaged at the time of an admission?

Yes

☐ Comments

No

☐


5b Are there processes to ensure that appropriate community based professionals remain involved throughout the episode of inpatient care?

Yes

☐ Comments

No

☐


5c Are there processes and protocols to plan for and support community transitions (including collaborative care planning and timely transfer of information and follow up)?

Yes

☐ Comments

No

☐
